Vertebroplasty and kyphoplasty for the treatment of vertebral compression fractures: an evidenced-based review of the literature

BackgroundVertebroplasty (VP) and kyphoplasty (KP) are routinely used to treat vertebral body compression fractures (VCFs) resulting from osteoporosis or vertebral body tumors in order to provide rapid pain relief. However, it remains debated whether VP or KP results in superior outcomes versus medical management alone in patients experiencing VCFs.PurposeTo determine the level of evidence supporting VP or KP for the treatment of VCFs.Study designSystematic review of the literature.Patient samplePatients with osteoporotic or tumor-associated VCFs.Outcome measuresSelf-reported and functional measures.MethodsWe reviewed all articles published between 1980 and 2008 reporting outcomes after VP or KP for osteoporotic or tumor-associated VCFs and rated the level of evidence and grades of recommendation (per North American Spine Society [NASS] guidelines) supporting the use of VP or KP for the treatment of VCFs.ResultsSeventy-four VP studies for osteoporotic VCF (1 level I, 3 level II, 70 level IV), 35 KP studies for osteoporotic VCF (2 level II, 33 level IV), and 18 VP/KP for tumor VCFs (all level IV) were reviewed. There is good evidence (level I) that VP results in superior pain control within the first 2 weeks of intervention compared with optimal medical management for osteoporotic VCFs. There is fair evidence (level II–III) that VP results in less analgesia use, less disability, and greater improvement in general health when compared with optimal medical management within the first 3 months after intervention. There is fair evidence (level II–III) that by 2 years after intervention, VP provides a similar degree of pain control and physical function as optimal medical management. There is fair evidence (level II–III) that KP results in greater improvement in daily activity, physical function, and pain relief when compared with optimal medical management for osteoporotic VCFs by 6 months after intervention. There is poor-quality evidence that VP or KP results in greater pain relief for tumor-associated VCFs.ConclusionsAlthough evidence suggests that physical disability, general health, and pain relief are better with VP and KP than those with medical management within the first 3 months after intervention, high-quality randomized trials with 2-year follow-up are needed to confirm this. Furthermore, the reported incidence of symptomatic procedure-related morbidity for both VP and KP is very low.     

Risks and benefits of percutaneous vertebroplasty or kyphoplasty in the management of osteoporotic vertebral fractures

Vertebral fracture (VF) is the most common osteoporotic fracture and is associated with high morbidity and mortality. Conservative treatment combining antalgic agents and rest is usually recommended for symptomatic VFs. The aim of this paper is to review the randomized controlled trials comparing the efficacy and safety of percutaneous vertebroplasty (VP) and percutaneous balloon kyphoplasty (KP) versus conservative treatment. VP and KP procedures are associated with an acceptable general safety. Although the case series investigating VP/KP have all shown an outstanding analgesic benefit, randomized controlled studies are rare and have yielded contradictory results. In several of these studies, a short-term analgesic benefit was observed, except in the prospective randomized sham-controlled studies. A long-term analgesic and functional benefit has rarely been noted. Several recent studies have shown that both VP and KP are associated with an increased risk of new VFs. These fractures are mostly VFs adjacent to the procedure, and they occur within a shorter time period than VFs in other locations. The main risk factors include the number of preexisting VFs, the number of VPs/KPs performed, age, decreased bone mineral density, and intradiscal cement leakage. It is therefore important to involve the patients to whom VP/KP is being proposed in the decision-making process. It is also essential to rapidly initiate a specific osteoporosis therapy when a VF occurs (ideally a bone anabolic treatment) so as to reduce the risk of fracture. Randomized controlled studies are necessary in order to better define the profile of patients who likely benefit the most from VP/KP.     

椎体后凸成形术与椎体成形术生物力学比较

目的比较椎体后凸成形术（KP）与椎体成形术（VP）对骨质疏松性椎体压缩骨折（OVCF）椎体力学性能的影响。方法5具尸体取20个胸腰段骨质疏松单椎体标本,按配对设计,分配为球囊扩张椎体后凸成形术组（KP组）和椎体成形术组（VP组）。经轴向加载压缩25%,制成椎体压缩骨折,记录制成骨折时的最大载荷及刚度数据。KP组将椎体压缩骨折标本行球囊扩张椎体后凸成形术;VP组将椎体压缩骨折标本行椎体成形术。然后将骨水泥强化治疗的椎体再次经万能力学试验机轴向加载,记录治疗后最大载荷及刚度数据。结果KP组和VP组骨折治疗后椎体最大载荷均分别明显高于骨折前（P〈0.01）,而椎体刚度差异无统计学意义（P〉0.05）。KP组与VP组间比较治疗后椎体最大载荷差异无统计学意义（P〉0.05）,椎体刚度差异无统计学意义（P〉0.05）。结论KP和VP均可明显增加OVCF椎体的抗压强度和恢复刚度。     

Open vertebral cement augmentation combined with lumbar decompression for the operative management of thoracolumbar stenosis secondary to osteoporotic burst fractures

Osteoporotic burst fractures with neurologic symptoms are typically treated with neural decompression and multilevel instrumented fusion. These large surgical interventions are challenging because of patients' advanced ages, medical co-morbidities, and poor fixation secondary to osteoporosis. The purpose of this retrospective clinical study was to describe a novel technique for the treatment of osteoporotic burst fractures and symptomatic spinal stenosis via a limited thoracolumbar decompression with open cement augmentation [vertebroplasty (VP) or kyphoplasty (KP)]. Indications for decompression and cement augmentation were intractable pain at the level of a known osteoporotic burst fracture with symptoms of spinal stenosis. As such, 25 patients (mean age, 76.1 years) with low-energy, osteoporotic, thoracolumbar burst fractures (7 males, 18 females; 39 fractures) were included. In all cases, laminectomy of the stenotic level(s) was followed by vertebral cement augmentation (9 VP; 16 KP). When a spondylolisthesis at the decompressed level was present, instrumentation was applied across the listhetic level (n = 9). Clinical outcome (1 = poor to 4 = excellent) was assessed on last clinical follow-up (mean, 44.8 wks). In addition, a modified MacNab's grading criteria was used to objectively assess patient outcomes postoperatively. Radiographic analysis of sagittal contour was assessed preoperatively, immediately postoperatively, and at final follow-up. The average time from onset of symptoms to intervention was 19 weeks (range, 0.3-94 wks). A mean of 1.6 fractures/patient was augmented (range, 1-3 fractures) and 2.8 levels were decompressed (range, 1-6 levels). No statistical difference in anatomic distribution or number of fractures between the VP and KP groups or in the instrumented versus noninstrumented patients was noted (P > 0.05). An overall subjective outcome score of 3.4 was noted. Twenty of 25 patients were graded as excellent/good according to the modified MacNab's criteria. The choice of augmentation procedure or use of instrumentation did not predict outcome (P = 0.08). Overall, 1.7 degrees of sagittal correction was obtained at final follow-up. One patient was noted to have progressive kyphosis after KP. The use of a limited-posterior decompression and open cement augmentation via VP or KP is a safe treatment option for patients who have osteoporotic burst fractures and who are incapacitated from fracture pain and concomitant stenosis. After thoracolumbar decompression, open VP/KP provides direct visualization of the posterior vertebral body wall, allowing for safe cement augmentation of burst fractures, stabilizing the spine, and obviating the need for extensive spinal reconstruction. Although clinically successful, this technique warrants careful patient selection.     

Indications and contraindications for vertebroplasty and kyphoplasty

Introduction

Vertebral fractures (VF) are a leading cause of morbidity in the elderly. In the past decade, minimally invasive bone augmentation techniques for VF, such as percutaneous vertebroplasty (VP) and kyphoplasty (KP) have become more widespread. According to the literature, both techniques provide significant pain relief. However, KP is more expensive and technically more demanding than VP. The current study surveyed German surgeons who practice percutaneous augmentation to evaluate and compare decisions regarding the implementation of these techniques. Is there a difference in the indications and contraindications of VP and KP compared with the interdisciplinary consensus paper on VP and KP of the German medical association in the treatment of VF?

Methods

A multiple choice questionnaire was designed with questions regarding diagnostic procedures, clinical and radiologic (AO classification) indications, as well as contraindications for both VP and KP. A panel of five experts refined the initial questionnaire. The final version was then sent to 580 clinics registered to practice KP in Germany. The statistical analysis was done by two authors, who collected the questionnaire data and Wilcoxon’s signed ranks test was performed for non-parametric variables with SPSS.

Results

327 of 580 questionnaires (56.4%) were completed and returned. 151 (46.2%) of participants were performing both procedures, and 176 (53.8%) performed KP only. Median duration from onset of acute pain to intervention was 3 weeks. For most participants (95.4%), consistent back pain at the fracture level with a visual analog scale score over 5 was the main clinical indication for VP and KP. A1 and A3.1 fractures from osteoporosis and metastasis were considered indications for KP. Osteoporotic A1.1 fractures were an indication for VP. Traumatic A3.2 fractures were not an indication for either procedure. Major contraindications to both procedures were active infection (94.7%), cement allergy (86.8%), and coagulation disorders (80.3%).

Conclusion

Vertebroplasty and kyphoplasty both have roles in the treatment of vertebral fractures. However, we could see differences in the indications for the two percutaneous techniques. Participants of this study found more indications for KP versus VP in cases of painful A1.2 and A3.1 fractures due to osteoporosis, metastasis, and trauma. About half of the respondents reported that VP is indicated for osteoporotic and pathologic A1.1 fractures. This study offers only limited conclusions. Open questionnaires and prospective data from all clinicians performing these procedures should be analyzed to offer more specific information.     

Vertebroplasty and kyphoplasty: complementary techniques for the treatment of painful osteoporotic vertebral compression fractures. A prospective non-randomised study on 154 patients

In a prospective study, we aimed to evaluate the potential use of kyphoplasty (KP) and vertebroplasty (VP) as complementary techniques in the treatment of painful osteoporotic vertebral compression fractures (VCFs). After 1 month of conservative treatment for VCFs, patients with intractable pain were offered treatment with KP or VP according to a treatment algorithm that considers time from fracture (Δt) and amount of vertebral body collapse. Bone biopsy was obtained intra-operatively to exclude patients affected by malignancy or osteomalacia. 164 patients were included according to the above criteria. Mean age was 67.6 years. Mean follow-up was 33 months. 10 patients (6.1%) were lost to follow-up and 154 reached the minimum 2-year follow-up. 118 (69.5%) underwent VP and 36 (30.5%) underwent KP. Complications affected five patients treated with VP, whose one suffered a transient intercostal neuropathy and four a subsequent VCF (two at adjacent level). Results in terms of visual analogue scale and Oswestry scores were not different among treatment groups. In conclusion, at an average follow-up of almost 3 years from surgical treatment of osteoporotic VCFs, VP and KP show similar good clinical outcomes and appear to be complementary techniques with specific different indications.     

Vertebroplasty and kyphoplasty: complementary techniques for the treatment of painful osteoporotic vertebral compression fractures. A prospective non-randomised study on 154 patients

In a prospective study, we aimed to evaluate the potential use of kyphoplasty (KP) and vertebroplasty (VP) as complementary techniques in the treatment of painful osteoporotic vertebral compression fractures (VCFs). After 1 month of conservative treatment for VCFs, patients with intractable pain were offered treatment with KP or VP according to a treatment algorithm that considers time from fracture (Δt) and amount of vertebral body collapse. Bone biopsy was obtained intra-operatively to exclude patients affected by malignancy or osteomalacia. 164 patients were included according to the above criteria. Mean age was 67.6 years. Mean follow-up was 33 months. 10 patients (6.1%) were lost to follow-up and 154 reached the minimum 2-year follow-up. 118 (69.5%) underwent VP and 36 (30.5%) underwent KP. Complications affected five patients treated with VP, whose one suffered a transient intercostal neuropathy and four a subsequent VCF (two at adjacent level). Results in terms of visual analogue scale and Oswestry scores were not different among treatment groups. In conclusion, at an average follow-up of almost 3 years from surgical treatment of osteoporotic VCFs, VP and KP show similar good clinical outcomes and appear to be complementary techniques with specific different indications.

     

Osteoporotic vertebral compression fracture pain (back pain): our experience with balloon kyphoplasty

AIM: The aim of this study is to evaluate the safety and effectiveness of antalgic and functional results after interdisciplinary approach and treatment of vertebral compression fractures (VCF) with percutaneous balloon kyphoplasty (KP) by the pain medicine specialist. METHODS: Between April and December 2004, after informed consent, 13 patients have been treated for a total amount of 15 KP. For L5 - T11 level spinal anesthesia was performed, above T11 local infiltration was used. The following parameters were recorded: intraoperative course, postoperative course, pain before and after treatment, vertebral height restoring and quality of life measuring on visual analogical scale (VAS) and quality of life questionnaire of the European Foundation for Osteoporosis (QUALEFFO) scale. RESULTS: No complications or adverse events were recorded. VAS values for pain were 6.2+/-2.1 preKP vs 3.3+/-1.7 and 4.5+/-1.1 respectively postKP and at follow-up, with statistically significant differences. Vertebral heights were 53.5+/-16%, 71.2+/-21% and 68.1+/-13.5%, preKP, postKP and at follow-up respectively, with statistically significant differences, similarly to quality of life related parameters and QUALEFFO score. CONCLUSION: Back pain due to vertebral compression fractures is a quite frequent diagnosis for the pain medicine specialist; KP is a new technique showing an association of a low incidence of complications with a success rate, both on pain control and on vertebral height restoring. In our study, KP proved to be a safe technique with a high success rate, both for pain relief and for vertebral height restoring, with immediate results and important consequences on the patient's quality of life, physical and mental status, with a low incidence of complications due also to the choice of performing this procedure in locoregional anesthesia.     

Biomechanical assessment of new surgical method instead of kyphoplasty to improve the mechanical behavior of the vertebra:Micro finite element study

AIM To reduce post treatments of kyphoplasty, as a common treatment for osteoporotic vertebrae.METHODS This study suggests a new method for treating vertebrae by setting the hexagonal porous structure instead of the rigid bone cement mass in the kyphoplasty(KP). The KP procedure was performed on the fresh ovine vertebra of the level L1. Micro finite element modeling was performed based on micro computed tomography of ovine trabecular cube. The hexagonal porous structure was set on one cube instead of the bone cement mass. For the implant designing, two geometrical parameters were considered: Spacing diameter and thickness.RESULTS The results of micro finite element analyses indicated the improvement in the mechanical behavior of the vertebra treated by the hexagonal porous structures, as compared to those treated by vertebroplasty(VP) and KP under static loading. The improvement in the mechanical behavior of the vertebra, was observed as 54% decrease in the amount of maximum Von Misses stress(improvement of stress distribution), in trabecular cube with embedded hexagonal structure, as compared to VP and KP. This is comparable to the results of the experimental study already performed; it was shown that the improvement of mechanical behavior of the vertebra was observed as: 83% increase in the range of displacements before getting to the ultimate strength(increasing the toughness) after setting hexagonal pearls inside vertebrae. Both the material and geometry of implant influenced the amount of Von Mises stress in the structure.CONCLUSION The new proposed method can be offered as a substitute for the KP. The implant geometry had a more obvious effect on the amount of Von Mises stress, as compared to the implant material.     

Minimally Invasive Vertebral Augmentation Techniques in Osteoporotic Fractures

Abstract Minimally invasive vertebral augmentation techniques fill the gap between conservative treatment and open surgical fusion in the treatment of osteoporotic vertebral fractures. Both vertebroplasty (VP) and kyphoplasty (KP) have proven to be effective in the reinforcement of a fractured vertebral body and provide pain relief, but both procedures have technical differences. Furthermore, patient selection criteria are still under debate, as no randomized comparison trials of VP and KP exist. A competitive environment has arisen between both methods. In the authors’ opinion, VP and KP do not replace, but complement each other and offer both potential benefits. It is the purpose of this article to outline the different kinds of application of both methods.     

单侧穿刺椎体成形术治疗不同骨密度脊椎压缩性骨折的疗效分析

目的评估单侧穿刺椎体成形术（PVP）治疗不同骨密度（BMD）脊椎压缩性骨折的临床疗效。方法2009年1月至2012年12月广州医科大学附属第一医院采用单侧穿刺PVP治疗86例脊椎压缩性骨折老年患者,根据术前BMD的不同分为A组（BMD〈—2.5 S,n=54）和B组（BMD≥—2.5 S,n=32）,比较两组手术前后疼痛视觉模拟量表（VAS）评分、术后椎体骨水泥填充效果及并发症发生情况。结果 86例患者获随访6~12个月（平均8.3个月）。两组术后VAS评分均优于术前,差异有统计学意义（P〈0.05）。对两组术前、术后VAS评分,并发症发生率进行比较,差异无统计学意义（P〉0.05）;A组椎体骨水泥填充优秀率高于B组（P〈0.05）,填充效果更为理想。结论单侧穿刺椎体成形术治疗不同BMD脊椎压缩性骨折,术后均能明显改善患者腰背部疼痛,疗效良好;在椎体骨水泥填充满意度方面,BMD更低的患者似乎更有优势,BMD可能是影响椎体骨水泥填充效果的重要因素。     

Extended interval for retrieval of vena cava filters is safe and may maximize protection against pulmonary embolism

BACKGROUND: Retrieval of optional vena cava filters (VCF) has been demonstrated to be safe and feasible in injured patients in 4 recent studies. However, 2 pulmonary emboli PE were reported in these studies with mean implant durations less than 19 days. In light of these occurrences, we changed our practice for VCF retrieval when patients had recovered from their injuries and at least 30 days after their discharge, or had been stable on therapeutic anticoagulation for deep venous thrombosis (DVT) or PE for at least 2 weeks. The aim of the current study was to assess the safety of this approach. METHODS: A review of prospectively collected data on optional VCF over a 16-month period. The filters were inserted prophylactically per an institutional practice guideline or for the presence of DVT or PE with a contraindication and/or complication to anticoagulation. All patients underwent duplex imaging of the lower extremities and had pre- and post- retrieval cavagrams. Demographics, duration of implantation, and complications were recorded. RESULTS: Eighty-three patients had optional VCF inserted since the change in our clinical practice. Indications included prophylaxis for high-risk trauma patients (n = 58), DVT or PE with acute contraindication to therapeutic anticoagulation (n = 22), or complications of anticoagulation (n = 3). Two patients developed lower extremity DVT after filter insertion and 1 patient developed a vena cava thrombosis. Retrieval was successful in 47 of 54 cases (87%) attempted. Median implantation duration was 142 days (range 17-475). A filter strut fracture occurred during retrieval without further consequences. No post-insertion or post-retrieval PE occurred in this study. CONCLUSION: Extended intervals for retrieval of VCF are safe and may maximize protection against pulmonary embolism.     

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??Prevent strategy of complications by applying vena cava filter ZHANG Fu-xian, LUO Xiao-yun, ZHANG Huan. Department of Vascular Surgery, Beijing Shijitan Hospital??Beijin 100038, Chnia.
Corresponding author ??ZHANG Fu-xian, E-mail?? fuxian@263.net
Abstract Deep venous thrombosis (DVT) is more and frequent disease in clinical practice and have a high morbidity rate. Pulmonary embolism (PE) is a associated serious complication after DVT. For the sake of the prevention PE after DVT , Vena Cava Filter(VCF) had be extensive applied in clinical practice. But along with the increment of the VCF application in quantity, some homologous complications appears continuously??Master vena cava filter application, consummate technical, standardize and elaborate management are the best way to avoid complications .     

Balloon kyphoplasty versus percutaneous vertebroplasty in treating osteoporotic vertebral compression fracture: grading the evidence through a systematic review and meta-analysis

Objective

To assess the safety and efficacy of balloon kyphoplasty (KP) compared with percutaneous vertebroplasty (VP) and provide recommendations for using these procedures to treat osteoporotic vertebral compression fractures (OVCF).

Methods

A systematic search of all studies published through March 2012 was conducted using the MEDLINE, EMBASE, OVID, ScienceDirect and Cochrane CENTRAL databases. The randomized controlled trials (RCTs) and non-randomized controlled trials that compared KP to VP and provided data on safety and clinical effects were identified. Demographic characteristics, adverse events and clinical outcomes were manually extracted from all of the selected studies. The evidence quality levels and recommendations were assessed using the GRADE system.

Results

Twelve studies encompassing 1,081 patients met the inclusion criteria. Subgroup meta-analyses were performed according to the study design. In the RCT subgroup, there were significant differences between the two procedures in short-term visual analog scale (VAS), long-term kyphosis angles, operative times and anterior vertebrae heights. In the cohort study subgroup, there were significant differences between the two procedures in short- and long-term VAS, short- and long-term Oswestry Disability Index (ODI), cement leakage rates, short- and long-term kyphosis angles, operative times and anterior vertebrae heights. However, there were no significant differences in long-term VAS or adjacent vertebral fracture rates in the RCT subgroup. There were no significant differences in short- or long-term VAS, short- or long-term ODI, cement leakage rates, adjacent vertebral fracture rates, short- or long-term kyphosis angles or anterior vertebrae heights in the CCT subgroup, and the adjacent vertebral fracture rates did not differ significantly in the cohort study subgroup. The overall GRADE system evidence quality was very low, which lowers our confidence in their recommendations.

Conclusions

KP and VP are both safe and effective surgical procedures for treating OVCF. KP may be superior to VP in patients with large kyphosis angles, vertebral fissures, fractures in the posterior edge of the vertebral body or significant height loss in the fractured vertebrae. Due to the poor quality of the evidence currently available, high-quality RCTs are required.     

Early experience with the retrievable OptEase vena cava filter in high-risk trauma patients.

OBJECTIVES: Prophylactic vena cava filters (VCF) are efficient in preventing pulmonary embolism. Filter retrieval avoids the potential long-term complications of permanent VCF. Clinical evaluation was focused on filter-related complications and feasibility of retrieval in high-risk trauma patients. METHODS: Analysis of single-institution consecutive case series of patients who received a prophylactic OptEase VCF after multiple trauma between 08/2003 and 12/2004. Data were collected prospectively. RESULTS: A total of 37 OptEase filters were inserted prophylactically after multiple trauma (median patient age 35 years, range, 17-73 years, median ISS 41, range, 17-59). All patients had contraindications for pharmacological prophylaxis for thromboembolic events. 32 filters (86%) were retrieved after 16 days (range, 7-25 days). 12 of 33 filters (36%) demonstrated trapped clots/thrombosis within the filter structure on pre-retrieval cavography. Two patients received anticoagulation before filter retrieval due to filter thrombosis (6%). Symptomatic PE was observed in 1 patient (3%) 5 days after VCF retrieval. Minor caudal filter migration was observed in 1 patient (3%). Overall mortality was 3%. CONCLUSIONS: Retrieval of the OptEase filter is safe and feasible. Temporary filter placement avoids possible long-term complications of permanent VCF. It is an efficient form of PE prophylaxis when temporary contraindications to anticoagulation are present.     

Long-term follow-up of trauma patients with a vena caval filter

BACKGROUND: Venous thromboembolism (VTE) is an important complication in blunt trauma patients. At our Level I trauma center, we had a deep venous thrombosis (DVT) rate of 3.2% from 1993 to 1997 despite an aggressive VTE prophylaxis program. During this time period, we placed vena caval filters (VCF) for both traditional and prophylactic indications. This project was developed to establish a VCF registry for trauma patients to determine the long-term complications of VCF placement. METHODS: A letter was sent to all trauma patients who had a VCF placed from 1993 through 1997. Patients were asked to return for a history and physical examination to detect signs and symptoms related to VTE, a duplex ultrasound of the inferior vena cava, and a plain abdominal radiograph to determine filter migration. RESULTS: There were 191 VCFs inserted in our trauma population from 1993 to 1997. There were 105 patients (75 male and 30 female) available for evaluation, with a mean follow-up of 28.9 months. Forty-one VCFs were placed in patients with DVT or pulmonary embolism, and 64 were placed in patients for prophylactic indications as per the guidelines developed by the Eastern Association for the Surgery of Trauma. There were no clinically identifiable complications related to insertion of the VCF. There were no pulmonary embolisms detected after VCF insertion. In follow-up, only one filter (0.95%) migrated, and this was minimal (1 cm cephalad). One (0.95%) vena cava was occluded, based on duplex ultrasonography, and 11 patients (10.4%) had signs or symptoms of leg swelling after hospital discharge. Twenty eight (44%) of the 64 patients with prophylactic VCFs developed a DVT after filter placement. CONCLUSION: VCFs placed in trauma patients have acceptable short- and long-term complication rates. Consideration should be given to prophylactic VCF placement in patients at high risk for VTE. Randomized controlled trials are needed to evaluate whether VCF insertion increases the risk for subsequent DVT.     

Risk factors for newly developed osteoporotic vertebral compression fractures following treatment for osteoporotic vertebral compression fractures

Background context

It has been reported that newly developed osteoporotic vertebral compression fractures (OVCFs) occur at a relatively high frequency after treatment. While there are many reports on possible risk factors, these have not yet been clearly established.

Vena cava filters: a synopsis of complications and related topics

Deep venous thrombosis and pulmonary embolism constitute common preventable causes of morbidity and mortality. The incidence of venous thromboembolism (VTE) continues to increase. Standard anticoagulation therapy may reduce the risk of fatal PE by 75% and that of recurrent VTE by over 90%. For patients who are not candidates for anticoagulation, a vena cava filter (VCF) may be beneficial. Despite a good overall safety record, significant complications related to VCF are occasionally seen. This review discusses both procedural and non-procedural complications associated with VCF placement and use. We will also discuss VCF use in the settings of pregnancy, malignancy, and the clinical need for more than one filter.     

Risk factors for the development of vertebral fractures after percutaneous vertebroplasty

We have recently observed an increased risk for vertebral fractures (VF) in a randomized controlled trial comparing the analgesic effect of vertebroplasty (VP) versus conservative treatment in symptomatic VF. The aim of the present study was to evaluate the risk factors related to the development of VF after VP in these patients. We evaluated risk factors including age, gender, bone mineral density, the number, type, and severity of vertebral deformities at baseline, the number of vertebral bodies treated, the presence and location of disk cement leakage, bone remodeling (determining bone turnover markers) and 25 hydroxyvitamin D [25(OH)D] levels at baseline in all patients. Twenty‐nine radiologically new VF were observed in 17 of 57 patients undergoing VP, 72% adjacent to the VP. Patients developing VF after VP showed an increased prevalence of 25(OH)D deficiency (<20 ng/mL) and higher P1NP values. The principal factor related to the development of VF after VP in multivariate analysis was 25(OH)D levels < 20 ng/mL (RR, 15.47; 95% CI, 2.99–79.86, p < 0.0001), whereas age >80 years (RR, 3.20; 95% CI, 1.70–6.03, p = 0.0007) and glucocorticoid therapy (RR, 3.64; 95% CI, 1.61–8.26, p = 0.0055) constituted the principal factors in the overall study population. Increased risk of VF after VP was also associated with cement leakage into the inferior disk (RR, 6.14; 95% CI, 1.65–22.78, p = 0.044) and more than one vertebral body treated during VP (RR, 4.19; 95% CI, 1.03–34.3, p = 0.044). In conclusion, nearly 30% of patients with osteoporotic VF treated with VP had a new VF after the procedure. Age, especially >80 years, the presence of inferior disk cement leakage after the procedure, the number of cemented vertebrae, and low 25(OH)D serum levels were related to the development of new VF in these patients, with the latter indicating the need to correct vitamin D deficiency prior to performing VP.     

Spontaneous umbilical CSF fistula in an adult as a complication of a ventriculoperitoneal shunt

Ventriculoperitoneal (VP) shunt is the most commonly used CSF shunt in the modern era and widely accepted for the management of hydrocephalus. Numerous abdominal complications have been reported in the literature. Spontaneous umbilical fistula from VP shunt, although uncommon, has been reported previously in children, but never in an adult. This is a case report on an adult who was treated for spontaneous umbilical fistula at our unit.